A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

"Do you feel you need treatment?"

"Who is the governor of this state?"

"What do you get when you subtract 7 from 100?"

"How do you get money for your needs?"

Answer and Explanation

The Correct Answer is A

A. "Do you feel you need treatment?"
Asking the client, "Do you feel you need treatment?" assesses their insight into their own mental health condition. Insight refers to the client's awareness and understanding of their illness, including recognizing the need for treatment. A positive response to this question indicates the client's awareness of their condition and willingness to seek help, demonstrating good insight.

B. "Who is the governor of this state?"
This question assesses the client's orientation to time, place, and current events. It is useful for assessing cognitive functioning but does not specifically measure insight into one's own mental health.

C. "What do you get when you subtract 7 from 100?"
This question assesses the client's cognitive functioning, specifically mathematical abilities. It is useful for evaluating cognitive skills but does not address insight into mental health.

D. "How do you get money for your needs?"
This question assesses the client's problem-solving abilities and understanding of practical matters. It is relevant for assessing functional abilities but does not specifically measure insight into their mental health condition.

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Correct Answer is A

Explanation

A. The nurse maintains confidentiality unless the client's safety is compromised:
Explanation: Maintaining confidentiality is a fundamental principle in nursing practice. Nurses are ethically and legally obligated to keep client information confidential, ensuring that the client's privacy is respected. Confidentiality builds trust between the nurse and the client, encouraging open communication. However, confidentiality can be breached if the client's safety is at risk, such as if they express suicidal or homicidal thoughts, indicating the need for intervention to ensure their well-being.

B. The nurse seeks to spend extra time specifically with the client each day:
Explanation: While it's important for nurses to spend adequate time with each client, seeking to spend extra time specifically with one client may create imbalances in care distribution. Nurses should strive to provide equitable care to all clients, addressing their needs based on assessments and care plans. Special attention to one client could lead to feelings of favoritism or neglect among other clients, affecting the therapeutic environment.

C. The client sees the nurse as an authority figure:
Explanation: Clients often view nurses as authority figures due to their expertise and role in healthcare. This perception can facilitate a therapeutic relationship, as clients may trust the nurse's guidance and care. However, this should be balanced with empathy and understanding to create a supportive and therapeutic environment.

D. The client regards the nurse as a friend:
Explanation: While a therapeutic nurse-client relationship aims for trust and rapport, it is not a friendship. The nurse maintains professional boundaries to provide objective care without personal bias. Friendship implies a level of personal involvement that can compromise the nurse's ability to make objective clinical decisions. A therapeutic relationship is built on trust, respect, empathy, and clear professional boundaries.

A. Pseudoephedrine B. Docusate sodium C. Ranitidine D. Ibuprofen

Correct Answer is A

Explanation

A. Pseudoephedrine
Clients taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) used to treat depression, need to avoid certain over-the-counter medications, especially those containing sympathomimetic amines like pseudoephedrine. Combining MAOIs with sympathomimetic medications can lead to a severe increase in blood pressure, potentially causing a hypertensive crisis.

B. Docusate sodium:
Docusate sodium is a stool softener and is generally safe to use with phenelzine. It does not have significant interactions with MAOIs.

C. Ranitidine:
Ranitidine is an H2 blocker used to reduce stomach acid production. It does not have significant interactions with phenelzine.

D. Ibuprofen:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. While it does not interact directly with phenelzine, individuals taking phenelzine should avoid other medications, especially NSAIDs, that can increase the risk of bleeding due to phenelzine's effects on platelet function. However, this interaction is not as severe as the interaction between phenelzine and sympathomimetic medications like pseudoephedrine.

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A nurse is conducting a mental status examination. Which of the following questions should the nurse ask to determine the client's insight?

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